What happened
On May 18, 2019, a Cessna T2-10N, registration PR-DVR, took off from the Brigadeiro Protásio de Oliveira Aerodrome in Belém, Brazil, for a local flight. The aircraft was carrying a pilot and three passengers. Shortly after departure, observers noted black smoke emitting from the aircraft's exhaust.
In an attempt to return to the airfield, the pilot initiated a left-hand turn. During this maneuver, the aircraft lost altitude and collided with a residential building. The impact caused substantial damage to the aircraft and the structure of the home, as well as damage to several nearby rooftops. The pilot sustained fatal injuries, while two passengers suffered serious injuries and one passenger sustained minor injuries.
The investigation
CENIPA's investigation focused on the mechanical state of the powerplant and the maintenance history of the aircraft. Investigators found that the engine was suffering from significant power loss due to a combination of fuel and air mixture imbalances. Specifically, the turbocharger was inefficient due to corrosion-related holes in the throttle body and cracks in the waste gate. Additionally, the fuel distributor (spider) had a stuck diaphragm cylinder, and oxides had migrated to and obstructed injector nozzles 3, 4, and 6, effectively disabling three cylinders.
The investigation also revealed that the aircraft had not been stored according to manufacturer specifications for an extended period, leading to widespread corrosion. Furthermore, the maintenance records for the airframe, engine, and propeller were found to be outdated. While recent 50-hour and 100-hour inspections had been performed, investigators determined that the maintenance organization failed to follow the manufacturer's service manual procedures during these inspections.
Findings
- Engine Failure: The engine experienced a significant reduction in power caused by blocked fuel injectors and an inefficient turbocharger.
- Improper Storage: The aircraft was not stored according to manufacturer guidelines, which allowed corrosion to compromise various engine components.
- Maintenance Oversight: The maintenance organization failed to properly supervise and execute inspections in accordance with the manufacturer's technical manual.
- Pilot Factors: The pilot's lack of experience with turbocharged engines and a history of not using checklists may have contributed to an improper fuel/air mixture, potentially leaving the auxiliary fuel pump on during takeoff.
- Inadequate Maneuvering: The decision to execute a left turn at low altitude and low power, combined with inadequate flight control inputs, led to the loss of control and the subsequent collision.